Anesthesia for pediatric dentistry.

The administration of anesthesia to young patients creates a unique series of problems for the anesthesiologist. This article details these various problems and tackles the primary challenge facing clinicians in this environment: providing an environment that allows technically complex dental treatment to be delivered without inflicting any adverse psychological impact on the child or physical harm to the child or others.

Anesthesia for endodontic practice.

The ability to provide excellent, high-quality pain control in endodontic practice is based on a practical knowledge of the indications and limits of intraoral local anesthesia. This article reviews clinically relevant aspects of anatomy, physiology, and pharmacology that contribute to the effective use of local anesthesia.

Managing the endodontic patient with disabling anxiety or phobia.

Disabling anxiety and phobia are commonly encountered in dental practice. Successful management of these patients is especially important in endodontic practice, where patients are often compelled to seek treatment because of acute or threatened pain. This article reviews the recognition and management of these common disorders. Mild anxiety can be managed with oral sedatives and/or nitrous oxide; however, moderate to severe anxiety and phobia is best treated with deep sedation or general anesthesia.

Myofascial pain syndrome: characteristics, diagnosis, and treatment.

Myofascial Pain Syndrome (MPS) is defined as a chronic muscle pain disorder associated with focal areas of exquisite tenderness called trigger points. It is a common cause of chronic orofacial pain and is commonly seen in patients with temporomandibular disorders. When stimulated, trigger points refer pain to surrounding areas, and the pain may resemble other conditions. Diagnosis of MPS is made by identifying trigger points and their associated pain referral pattern. Physical therapy maneuvers and injection are the most common and successful treatments. Eradication of trigger points can diminish or eliminate the pain associated with this syndrome.

Sustained relief of oral aphthous ulcer pain from topical diclofenac in hyaluronan: a randomized, double-blind clinical trial.

OBJECTIVES: The purpose of this study was to test the hypothesis that topically applied 3% diclofenac in 2.5% hyaluronan reduces aphthous ulcer pain. STUDY DESIGN: A randomized, double-blind, single dose study of 60 healthy adults with aphthous ulcers in three treatment groups--3% diclofenac in 2.5% hyaluronan, 2.5% hyaluronan, 3% viscous lidocaine--was undertaken. Visual analogue scale pain scores were obtained before and after gel application and hourly, for up to 8 hours after gel application. Statistical analysis was performed with repeated measures ANOVA with square root transformation and Bonferroni correction. RESULTS: A 48% overall reduction in pain (p < 0.01) was observed 10 minutes after gel application; however, no significant difference was found between the three topical agents. A 35% to 52% pain reduction (p < 0.01) was reported 2 to 6 hours after the application of diclofenac in hyaluronan, whereas hyaluronan gel alone and viscous lidocaine failed to produce significant VAS reductions. CONCLUSIONS: A dose of 3% diclofenac in 2.5% hyaluronan is an effective and novel treatment for this common, painful disorder.

Local anesthetic effects in the presence of chronic osteomyelitis (necrosis) of the mandible: implications for localizing the etiologic sites of referred trigeminal pain.

The aims of this study were: (1) to demonstrate how reproducible variations in incomplete anesthesia of the inferior alveolar nerve can be used as a guide to locate the etiologic sites of referred trigeminal pain emanating from the mandible; (2) to describe the salient histopathologic features of a lowgrade, nonsuppurative osteomyelitis seen in this patient population. Forty-six patients with idiopathic facial pain were subjected to a specific protocol of local anesthetic injections to sequentially block branches of the mandibular nerve to determine the effects on his/her pain. If this significantly reduced or altered the pain on three separate appointments, then exploratory surgery was conducted near identified zones of unanesthetized gingiva. Blocking (92%), bridging (4%), and divergence (4%) were observed patterns of anesthetic resistance of the mucogingival tissues used to categorize the incomplete anesthesia. A 100% correlation was found between the identified zones of unanesthetized gingiva and the discovery of intramedullary pathology. Medullary fibrosis with ischemic and degenerative changes in the cancellous bone were common findings, along with chronic inflammatory cell infiltrates and clusters of lymphocytes. It is concluded that Ratner's method of diagnostic anesthesia be implemented when searching for occult pain producing pathology of the jaws.

An unusual case of sympathetically maintained facial pain complicated by telangiectasia.

A 32-year-old woman with a history of maxillary sinusitis, multiple surgical interventions in the maxillary sinus, and a hyperalgesic, erythematous skin lesion in her left infraorbital area, had severe burning pain in the left face. The dermal lesion was diagnosed as atypical telangiectasia and the sinus pathoses determined to be unrelated to her symptoms. Two diagnostic stellate ganglion blocks were performed with concurrent bilateral monitoring of blood flow in the infraorbital skin. Blood flow was significantly increased in the painful erythematous patch although no significant change in flow occurred in the unaffected contralateral skin. The changes correlated to patient's relief from pain. The patient's symptoms were subsequently controlled with an oral sympatholytic agent. This article demonstrates the usefulness of laser doppler flowmetry to establish the diagnosis of sympathetically maintained facial pain despite several confounding conditions and supports the theory that sympathetically maintained pain involves altered function of alpha-1 adrenoreceptors.

The hypothermic and antinociceptive effects of intrathecal injection of CGRP (8-37) in mice.

Calcitonin gene-related peptide (CGRP) and the selective antagonist properties of the peptide fragment of CGRP [CGRP (8-37)] have been the subjects of numerous investigations. These data represent the first demonstration of the hypothermic and antinociceptive effects of CGRP (8-37). Intrathecal injection of CGRP (8-37) in mice produced hypothermia which differed from that produced by CGRP in time course, duration of action and potency. CGRP and CGRP (8-37) did not alter blood flow. Thus, a direct vasodilatory action was not responsible for the acute hypothermic effects of the drugs. The combination of CGRP and CGRP (8-37) resulted in a decrease in body temperature which was no greater than that of either drug alone. We failed to observe any significant antinociceptive effect in the tail-flick assay after i.t. injection of CGRP (8-37), but dose-dependent antinociception was produced by CGRP (8-37) in the p-phenylquinone (PPQ) assay, with an ED50 value of 6.0 micrograms. However, CGRP (8-37) failed to block or enhance the antinociception produced by CGRP over a wide dose range. In addition to demonstrating an agonist-like effect for CGRP (8-37), these data also indicate that CGRP and CGRP (8-37) may not act through a common mechanism.

Respiratory effects of a balanced anesthetic technique--revisited fifteen years later.

Five hundred and fifty patients underwent general anesthesia with fentanyl, diazepam, and methohexital. Forty-seven (8.5%) developed signs of hypoventilation or airway obstruction. Arterial blood gas analysis revealed mild hypoxemia in three of the 47 cases and mild hypercarbia in six. Airway obstruction was more predictive of abnormal blood gas values than was hypoventilation.

The mouse paw withdrawal assay: a method for determining the effect of calcitonin gene-related peptide on cutaneous heat nociceptive latency time.

Previously we have shown that calcitonin gene-related peptide (CGRP) modulates nociception and the effect of opioid analgesics in the central nervous system of mice. Cutaneous primary afferent nerve terminals also contain a high concentration of CGRP, however the lack of a suitable method for assessing cutaneous nociceptive latency changes in the hindpaw skin of the mouse hindered our investigations. We report here on the development of an assay to investigate the effect of CGRP on nociception in the dorsal hindpaw skin. Subcutaneous injection of CGRP produced a modest elevation of withdrawal latency time at doses that were two orders of magnitude greater than the physiologic levels determined in naive animals by radioimmunoassay. This elevation of threshold was minimal when compared to the elevation produced by mepivacaine. These results indicate that subcutaneous injection of CGRP into the dorsal hindpaw skin of the mouse produces a modest increase in paw withdrawal latency times at high, non-physiologic doses.